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Monday, December 1, 2008

Guest Post: Do-It-Yourself...?

Every day, I grope for new ideas to save time and help get everything done, despite knowing *it won't ever all get done*. I usually manage to just keep my head above water, but there's always this panicky feeling of near drowning in the sea of work.

It is popular everywhere, evidently, to employ physician extenders to help get it all done. PAs triage patients in the ER and treat the more straightforward problems. Nurse practitioners make rounds on the critical care patients and the cancer patients, writing the detailed progress notes before the doctors arrive. They do casting for the orthopedists and see routine followups at the family practitioner's office. There's even a push for them to write prescriptions, although that's not happened yet in our state.

One of my partners has a PA. He sees 90% of his post-op patients at followup in the office, sees new hospital consults, does all his medical records, and screens all his incoming pages on call. He also often is the only person to see my hospital inpatients on the weekends when they're on call. This frees my partner up to be more productive and to have more time at home with his family.

So what's the matter with me? I admit, it's been very tempting to engage a PA myself. I'd love to have someone else dictate all those discharge summaries. I might even be able to see my family 5 nights a week instead of 3. How can that be a bad thing? Why don't I just hire somebody to help? *Everybody else is doing it!*

I just can't do it. Maybe it's a little OCD, but I keep hearing my mom saying to me years ago, "If you want a job done right, do it yourself." It's the mantra of my Type A surgical personality. I know you can't really do *everything* yourself, which is why we have an office staff. But when it comes to patient care, it's a different story.

My patients come to me because they trust me to help them. Most are in pain or critically ill, and they're vulnerable in so many ways. They are *my* responsibility. No one else can evaluate them initially, because I have to make the decisions about what patients need surgery. No one without surgical training can or should do that. In the hospital postop, there are so many subtle things that can go wrong, I don't feel comfortable letting anyone else other than my partners make rounds. (I dislike my partner's PA seeing my patients when they're on call, and my patients have told me they don't like it, either.)

In the office postop, patients want to see their surgeon, not somebody else. I want to see them, because it's rewarding seeing how they've (usually) improved as a result of what I've done. I hear patients complain frequently that "when I go to my family doctor, I never see him, just the nurse practitioner." (That attitude may be unfair to a very good nurse practitioner, but it's that patient's real response.) To me, it's important to nurture my rapport with each patient. I can't do that if I don't see them and talk to them.

There are real legal issues, too. If my PA misses something resulting in a bad outcome, that's my responsibility, and I take the heat. If my PA doesn't document something adequately, that can mushroom into a huge problem under the right circumstances. And if I check everything a PA does, it's not worth having them, because I might as well just do the work myself.

This is not to insult physicians who employ physician extenders or to insult the physician extenders themselves. It may be that with the growing population and the physician shortage, my approach may not be workable or realistic, just like house calls are a thing of the past. I may one day eat these words.

But for now, I'll keep treading water, doing my own thing.

gcs 15 is a 39 year old full-time neurosurgeon in private practice in a beautiful Southern state. She has a 10 year old son who plays travel soccer and ice hockey. Her wonderful, Type B husband is a primary care MD who quit medicine to be a college professor and loves teaching premed students. She adores her job but hates the politics involved in the practice of medicine. She's always struggling to find ways to get more hours in the day.

10 comments:

My partners want their assistants to ask "why are you here today?" when the assistant rooms a patient. I won't practice that way. I'm a primary care doc. The interview is one of the most important parts of my job, and I won't let anyone else do any part of it. I just want my assistant to weigh my patients and get them in rooms. And maybe check if they've had any lab work done since the last visit, but even that question changes the dynamic and can shift the agenda away from the patient's real concerns.

We have an NP who sees acute patients for same-day appointments, and my patients are generally grateful for the access, but I do all my own follow-ups and I intend to continue doing so.

I agree that use of physician extenders is troublesome; can leave us responsible for someone else's work. I have a 4 physician (all "mothers in medicine") primary care practice in which we only use med. assistants, to get vital signs, EKG, do venipuncture, pull labs, etc. But all exams and medical decision making are done by the physician. Remember, in the eyes of the insurance companies we are all just "providers", and I fear that eventually there will be no payment to physicians for all these services now being done by "extenders". We see this now in primary care, where certain companies will waive co-pay, thereby offering a free visit, if patient goes to retail walk-in clinic. Same clinic has blown off as "viral" a total lobar pneumonia in one of my patients.

I have a very good friend who had a brain tumor removed a few years ago. His surgeon never came by to see him post op. He was seen by a nurse practitioner on rounds, and was discharged by the nurse practitioner. He would ask for the surgeon to come by, to see him even once in the several days he was there post op. He was told several times that the surgeon was in the hospital, was doing rounds, yet he never came by.

At the time, I was an aspiring pre med student. Now I am a second year in med school. Maybe I am still idealistic, but I was horrified. Yes, being seen by the practitioner you chose (and paid for) with complete follow up is important in all aspects of medicine, whether it be a family doc or whatever.

But post brain surgery? I would think this would even more important. I wish he had you as his neurosurgeon.

I've worked with NPs before and they are awesome, but I do agree with Hillary - patients want (and NEED) to see their physicians. I'll admit that now that I'm the only one practicing on my license, I feel a bit more at ease.

We have 2 very powerful nurse practitioners in our primary care office who have a very large and loyal panel of patients. They have a tremendous amount of autonomy. They write their own prescriptions, do their own injections (i.e. trigger point, joint, muscle), order their own meds (i.e. IV/IM meds), and so on. The dynamics of my clinic are very unusual, and interestingly, most patients here (rural, small town) don't know the difference between seeing them versus seeing a physician. I won't comment much more, except just to add that I think there is a role for physician extenders, but I would not feel comfortable directly supervising a physician extender unless I trusted their knowledge base and judgement. Based on what I've seen so far, I think I'm also too OCD to feel totally comfortable using a physician extender - I would criticize overuse of antibiotics, inappropriate use of labwork, etc. I might as well just do it myself!

In primary care, another role for extenders I have seen is to see the patient for the initial visit. Specifically, I have seen this in surgical practices, in which the extender decided whether or not surgery is needed. If it is needed, they are then seen by the physician. Not only do my patients not appreciate this, I don't appreciate it either. Specifically, I have usually sent a patient to see a specialist b/c the problem is beyond my scope. I generally feel that my years in med school, residency, and practice, have at least trained me enough to decide whether or not a specialist is needed. To have my decision undermined by a person without an equivalent training is somewhat troublesome. I have to admit, I generally do not refer again to those physicians.

i couldn't agree more. as a surgeon myself, i prefer to see my post-op patients, dictate, write notes myself. i notice that my male counterparts don't have a problem using physician extenders and i often wonder if i'm being too OCD and not making the most of the PA's, NP's. in other words, are we the ones making our lives more difficult by being too controlling?

WOW! As a mother and physician assistant, I am saddened (but actually not surprised) by your distaste for physician extenders. Most of us have no desire to steal your patients away. Our goal is to make your job easier. We ARE trained to do exams and medical decision making, and if you utilize us properly, we can see the more routine cases, freeing up your time for the more involved ones. In the OBGYN practice I work in, I have my own following of patients that actually call in and ASK to see me. Of course, our patients are ALWAYS free to see the physicians, but most are happy to be seen by me (especially for routine GYNE concerns) which almost always guarantees them an earlier visit. I am fully aware of my limitations and have no problem seeking advice from my supervising physician if I am in over my head. I know I am not a doctor, nor do I try to act like one. But I am confident in my clinical skills, and I do think I have a valuable role in health care. Many of the speciality PAs I know see the patient when they are first referred and perform some of the intake work (initial H&P, obtaining necessary lab and imaging studies, etc.) and then the MD sees the patient once he/she has all of the data. Yes as a physician, you (the referring doctor) know when a patient needs to be referred to a specialist. But to outright dismiss a physician extender (with training in that specific speciality) simply because they did not go to medical school is a bit arrogant. I guess the situations some of you are describing (where the MD never sees the patient until the actual surgery, and then never again) is bothersome, especially for the patient and the referring physician. Physician extenders CAN be a wonderful asset to a practice, both solo and group ones. I hope some of you get to work with good PAs/NPs and maybe we can change your mind.

I do not use any specialist who uses an extender for the initial visit EVER AGAIN. There is a GI in town who has his NP see new patients and arrange their procedures without the patient ever seeing the MD. I know this because one of my patients told me she refused to sign her consent for her colonoscopy (in the preop area, mind you) because she hadn't met the guy-and she was quite right. I have also seen some truly awful things from the "retail 'clincs'" as well as other practices, to wit overuse/misuse of advanced studies and specialist referrals. Extenders tend to cost the health care system more rather than less because of this. All that being said, there is a place for them, just not in the previously mentioned situations. And remember folks, since YOU are responsible for the outcome, you'd better know your extender VERY well if you choose to use one.

I am not sure how I would fit in this conversation as a certified nurse-midwife. I am not a 'physician extender', and find that term highly offensive. I do not work as an extension of the physicians in my office. I provide a service that few physicians are capable of providing or may not be willing to provide. But this is an area different than surgery. I can't speak to that area.

Mothers in Medicine is a group blog by physician-mothers, writing about the unique challenges and joys of tending to two distinct patient populations, both of whom can be quite demanding. We are on call every. single. day.

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